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Ventriculoatrial Shunt Placement Technique

  • Author: Todd C Hankinson, MD, MBA; Chief Editor: Jonathan P Miller, MD  more...
 
Updated: Mar 11, 2016
 

Approach Considerations

Before preparing the field, perform a trial fluoroscopy to be certain that the appropriate anatomic landmarks are easily visualized.

In order to prevent backflow of blood and subsequent thrombosis and catheter occlusion, flush the distal catheter with heparinized saline immediately before connecting it to the proximal aspect of the system, and occlude the catheter until it is connected. Place the distal tip of the atrial catheter in the middle to lower atrium, approximately the T6 level.

Administer antibiotics preoperatively, and adhere to sterile technique to minimize the risk of infection.

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Placement of Ventriculoatrial Shunt

Placement of the ventricular catheter does not differ significantly from other cerebrospinal fluid (CSF) shunt operations. In other shunt cases, the authors choose to place the ventricular catheter as one of the final steps in the procedure to minimize the risk of dislodgment. However, in the case of ventriculoatrial shunts, the authors place the ventricular catheter and valve before accessing the distal vessel in order to minimize the risk of distal catheter malposition or backflow.

If the ventricular catheter is placed frontally, a length of distal shunt tubing is secured to the outflow port of the unidirectional shunt valve. A 1-cm vertical retroauricular incision is made, and the tubing is pulled subcutaneously out through this incision. A hemostat or temporary suture is placed to prevent CSF egress. If the ventricular catheter is placed through an occipital burr hole, the distal shunt tubing is tunneled directly to the proposed site of entry for vascular access.

A percutaneous (Seldinger) or open vascular cutdown technique may be used to access the appropriate vessel for atrial catheter positioning. The authors prefer a percutaneous technique, which is similar to that used for the placement of central venous catheters. Ultrasonographic guidance may be used to facilitate access.

The internal jugular vein is the most commonly selected access vessel. An appropriately sized (often 20 or 22 gauge) needle is used to puncture the skin one to three fingerbreadths (depending on the size of the patient) above the clavicle, between the heads of the sternocleidomastoid muscle. If subclavian vein access is chosen, the entry site is inferior to the clavicle, at the junction of the middle and lateral third of the bone.

After successful cannulation of the vessel, a flexible guide wire is passed through the needle, and the tip is positioned in the superior vena cava or cardiac atrium under fluoroscopic guidance. Instability on electrocardiography (ECG) may indicate that the guide wire is positioned within the heart. The needle is then removed, and a nick incision is made to facilitate dilator entry. The authors prefer to load the peelaway sheath on the dilator and pass them together into the vessel. Occasional advancing and retracting of the guide wire ensures that the dilator is following the wire’s subcutaneous course.

The dilator and guide wire are then removed, and the shunt tubing is passed down the peelaway sheath. Brisk back-bleeding is often encountered upon removal of the dilator. The authors find it most effective to pass the distal shunt well beyond the lower atrium before splitting and removing the peelaway sheath; it is not always possible to advance the shunt tubing once the sheath is removed. The catheter is then pulled back to an appropriate final position (as described in more detail below), flushed with heparinized saline, and connected to the proximal shunt system.

An open approach can also be used to gain access to the vascular system. A cutdown is made to the internal jugular vein, where a purse-string suture is placed on the anterior wall of the vein. A stab incision is made inside the purse-string, and the catheter is place directly into the vein. The suture is then tied down around the catheter to stop any back-bleeding.

A third technique is to isolate the transverse facial vein as it enters the internal jugular vein. This vein can then be divided and the shunt passed down into the internal jugular vein. A tie is used to secure the catheter to the transverse facial vein and to prevent back-bleeding.

The position of the distal catheter tip is verified by means of fluoroscopy. The tip of the distal catheter is optimally positioned in the middle to lower atrium, at approximately the T6 vertebral body level. If the tip is not clearly visualized, injection of a small volume of radiopaque contrast material may facilitate fluoroscopic visualization. Other techniques, including recording pressure waves through the catheter or using the catheter as an ECG lead, may also be used.

Once satisfactory positioning of the atrial catheter has been achieved, the proximal and distal catheters are trimmed in such a way as to allow a small amount of redundancy. Excellent flow of CSF through the proximal catheter system is verified, and the distal catheter is flushed with heparinized saline and connected to the proximal catheter using a straight connector. The incisions are thoroughly irrigated with antibiotic-impregnated saline and closed in layers.

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Complications

Complications of ventriculoatrial shunt placement may include the following:

  • Shunt-induced immune-complex glomerulonephritis - Chronic shunt infection with Staphylococcus epidermidis may result in immune complex deposition at the renal glomerulus, causing severe glomerulonephritis: this injury generally responds immediately to externalization of the shunt and appropriate antibiotic therapy
  • Pulmonary hypertension due to microemboli - A catheter within the cardiac atrium may casue chronic microembolization and thus result in pulmonary hypertension
  • Endocarditis
  • Wound/CSF shunt infection - CSF shunt infection rates vary but are commonly reported to be in the approximate range of 5-8%; a CSF shunt infection warrants removal of the shunt and placement of an external ventricular drain during antibiotic treatment of the infection
  • Outgrowing the shunt - As a child with a ventriculoatrial shunt grows, the shunt will slowly back out of the atrium, a process that potentially leads to shunt malfunction
  • ECG instability
  • Shunt malfunction - All shunts are prone to malfunction, at a rate of 40% in the first 2 years after insertion or revision; patients and their families should be aware of this and take appropriate action should it occur

Superior vena cava thrombosis is a rare complication of ventriculoatrial shunt placement.[3]

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Contributor Information and Disclosures
Author

Todd C Hankinson, MD, MBA Assistant Professor of Neurosurgery, Children's Hospital Colorado, University of Colorado School of Medicine

Todd C Hankinson, MD, MBA is a member of the following medical societies: American Association of Neurological Surgeons, Congress of Neurological Surgeons, International Society of Pediatric Neurosurgery, American Society of Pediatric Neurosurgeons

Disclosure: Nothing to disclose.

Chief Editor

Jonathan P Miller, MD Director, Functional and Restorative Neurosurgery Center, Associate Professor of Neurological Surgery, George R and Constance P Lincoln Endowed Chair, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine

Jonathan P Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, American Medical Association, Congress of Neurological Surgeons, American Society for Stereotactic and Functional Neurosurgery, North American Neuromodulation Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Medtronic Neuromodulation.

References
  1. McGovern RA, Kelly KM, Chan AK, Morrissey NJ, McKhann GM 2nd. Should ventriculoatrial shunting be the procedure of choice for normal-pressure hydrocephalus?. J Neurosurg. 2014 Jun. 120 (6):1458-64. [Medline]. [Full Text].

  2. Machinis TG, Fountas KN, Hudson J, Robinson JS, Troup EC. Accurate placement of the distal end of a ventriculoatrial shunt with the aid of real-time transesophageal echocardiography. Technical note. J Neurosurg. 2006 Jul. 105(1):153-6. [Medline].

  3. Al-Natour MS, Entezami P, Nazzal MM, Casabianca AB, Assaly R, Riley K, et al. Superior vena cava syndrome with retropharyngeal edema as a complication of ventriculoatrial shunt. Clin Case Rep. 2015 Oct. 3 (10):777-80. [Medline].

  4. Yavuz C, Demirtas S, Caliskan A, Kamasak K, Karahan O, Guclu O, et al. Reasons, procedures, and outcomes in ventriculoatrial shunts: A single-center experience. Surg Neurol Int. 2013. 4:10. [Medline]. [Full Text].

 
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Ventriculoatrial shunt placement: Anteroposterior radiograph.
Ventriculoatrial shunt placement: Lateral radiograph.
 
 
 
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